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PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> SITE NAME ADDRESS �� a CITY <br /> OWNER NAME OWNER PHONE # S- <br /> CONTRACTO S. CONT. PHONE <br /> FIRE PERMIT # <br /> REMOVALID_ CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR t DATE l TANK if 39 <br /> METHOD RINSE AMOUNT <br /> R RINSED2�) _ <br /> I <br /> N RINSATE DISPOSAL SITE <br /> E MANIFEST # CQ 30-7 OR OTHER <br /> V VAPORS PURGED 01-0 METHOD AMOUNT IISID a� <br /> A <br /> P READING AT REMOVAL L.E.L. : D 02: O� <br /> 0 <br /> R COMMENTS <br /> C TANK MATERIAL , FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD POO HOLES) <br /> S <br /> T PIPE MATERIAL (STEEL , OTHER) Io FEET <br /> PIPE CONDITION (GOOD; 1ggii� HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> T I dc <br /> lJ <br /> A <br /> N <br /> 42R <br /> S EXCAVATION SIZE 1.42X 141 X _ YDS OF SOIL (O0� <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE # <br /> P P <br /> L I <br /> I P <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 it HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE MIXTURE: VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />